Medical Policy Updates: Third Quarter 2016

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1 Medical Policy Updates: Third Quarter 2016 Medical guidelines are written to address frequently occurring clinical situations. Medical policies are not medical advice and do not guarantee any results or outcomes. We review and update medical policies and guidelines regularly. In addition to updating existing medical policies, we also review frequently occurring clinical situations and may create new medical policies. We recently reviewed these medical policies. Please be sure to read the actual medical policies for details. CAM Policy Name Review Date Accelerated Breast Irradiation After Breast-Conserving Surgery for Early Stage Breast Cancer and Breast Brachytherapy as Boost with Whole Breast Irradiation Acoustic Cardiography Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses Ado-Trastuzumab Emtansine (Trastuzumab-DM1) for Treatment of HER-2 Positive Malignancies Allogeneic Hematopoietic Stem-Cell Transplantation for Genetic Diseases and Acquired Anemias Allogeneic Hematopoietic Stem-Cell Transplantation for Myelodysplastic Syndromes and Myeloproliferative Neoplasms Ambulance and Medical Transport Services Amniotic Membrane and Amniotic Fluid Injections 047 Amniotic Membrane and Limbal Stem Cell Transplantation for the Treatment of Ocular Conditions Artificial Intervertebral Disc: Cervical Spine Auditory Brainstem Implant Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions Autologous Hematopoietic Stem-Cell Transplantation for Malignant Astrocytomas and Gliomas Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients With Elevated Office Blood Pressure Back School Balloon Sinuplasty for Treatment of Chronic Sinusitis Baroreflex Stimulation Devices Beta Amyloid Imaging with Positron Emission Tomography (PET) for Alzheimer's Disease Bevacizumab in Advanced Adenocarcinoma of the Pancreas Biochemical Markers of Alzheimer s Disease Biofeedback as a Treatment of Headache Biofeedback for Miscellaneous Indications Biomarker Genes for Detection of Lymph Node Metastases in Breast Cancer 1

2 20415 Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Diseases Associated with High Bone Turnover 049 Brain Natriuretic Peptide (BNP) 046 Breast Pumps 079 Breast Surgical Procedures/Prosthesis Canalith Repositioning as a Treatment of Benign Paroxysmal Positional Vertigo (BPPV) Cardiac Rehabilitation in the Outpatient Setting Catheter Ablation as Treatment for Atrial Fibrillation Cervical Cancer Screening Technologies with Pap and HPV Cervicography Chelation Therapy for Off-Label Uses Chronic Intermittent Intravenous Insulin Therapy (CIIIT) Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy) Closure Devices for Patent Foramen Ovale and Atrial Septal Defects (ASD) Cochlear Implant Cognitive Rehabilitation 028 Colorectal Cancer Screening Composite Tissue Allotransplantation of the Hand and Face Computed Tomography (CT) Perfusion Imaging of the Brain Computed Tomography to Detect Coronary Artery Calcification Computer-Aided Evaluation of Malignancy with Magnetic Resonance Imaging of the Breast Computerized 2-lead Resting Electrocardiogram Analysis for the Diagnosis of Coronary Artery Disease 017 Contraceptive Management 138 Corporate Administrative/Medical Policy Guidelines (Medical Necessity, Investigational/Experimental) Correlated Audioelectric Cardiography Cranial Electrotherapy Stimulation (CES) and Auricular Electrostimulation Cryosurgical Ablation of Miscellaneous Solid Tumors Other Than Liver, Prostate Tumors or Dermatologic Tumors 048 CT Scanning of the Chest (Thorax) and Chest (Non-Coronary) Computed Tomography Angiography (CTA) Cutaneous Electrogastrography (EGG) Diagnosis and Treatment of Chronic Cerebrospinal Venous Insufficiency in Multiple Sclerosis Discectomy Dopamine Transporter Imaging with Single Photon Emission Computed Tomography (DAT-SPECT) 468 Drug Coverage Dynamic Cardiomyoplasty Electrical Impedance Scanning of the Breast Electrical Stimulation for the Treatment of Arthritis Electrocardiographic Body Surface Mapping Electrostimulation and Electromagnetic Therapy for the Treatment of Chronic Wounds 2

3 20217 End Diastolic Pneumatic Compression Boot as a Treatment of Peripheral Vascular Disease or Lymphedema Endobronchial Valves Endometrial Ablation Endovascular Stent Grafts for Abdominal Aortic Aneurysms Endovascular Stent Grafts for Disorders of the Thoracic Aorta Epithelial Cell Cytology in Breast Cancer Risk Assessment and High-Risk Patient Management (Ductal Lavage and Suction Collection Systems) Esophageal ph Monitoring Extracorporeal Photopheresis Extracorporeal Shock Wave Therapy in the Treatment of Peyronie's Disease Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome FDG Using Camera-Based Imaging (FDG-SPECT) Fecal Microbiota Transplantation Gene Expression Profiling for Uveal Melanoma Genetic Testing for Duchenne and Becker Muscular Dystrophy Genetic Testing for FMR1 mutations (including Fragile X Syndrome) Genetic Testing for Heterozygous Familial Hypercholesterolemia Genetic Testing for Li-Fraumeni Syndrome Genetic Testing for Mental Health Conditions Genetic Testing for Tamoxifen Treatment Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies Genetic Testing of Mitochondrial Disorders Heart Transplant Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma Hematopoietic Stem-Cell Transplantation for Acute Myeloid Leukemia Hematopoietic Stem-Cell Transplantation for Autoimmune Diseases Hematopoietic Stem-Cell Transplantation for Breast Cancer Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma Hematopoietic Stem-Cell Transplantation for Epithelial Ovarian Cancer Hematopoietic Stem-Cell Transplantation for Hodgkin Lymphoma Hematopoietic Stem-Cell Transplantation for Miscellaneous Solid Tumors in Adults Hematopoietic Stem-Cell Transplantation for Non-Hodgkin Lymphomas Hematopoietic Stem-Cell Transplantation for Plasma Cell Dyscrasias, Including Multiple Myeloma and POEMS Syndrome Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia Hippotherapy Home Prothrombin Time Monitoring Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease H-wave Electrical Stimulation Ilizarov Bone-Lengthening Procedure Immune Cell Function Assay Immune Prophylaxis for Respiratory Syncytial Virus Implantable Sinus Stents for Postoperative Use Following Endoscopic Sinus Surgery 3

4 50115 Infliximab 015 Influenza Vaccine Inhaled Nitric Oxide Intensity-Modulated Radiotherapy of the Breast and Lung Intensity-Modulated Radiotherapy of the Prostate Intensity-Modulated Radiotherapy: Cancer of the Head and Neck or Thyroid Intensity-Modulated Radiotherapy: Central Nervous System Tumors Interlukin 2 as a Treatment for HIV Infection Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain Intradialytic Parenteral Nutrition Intratympanic Injections of a Pharmacologic Agent for the Treatment of Meniere's Disease or Sudden Hearing Loss Intravascular Brachytherapy for Preventing and Managing Restenosis after Percutaneous Transluminal Angioplasty (PTA) 091 Ipilimumab (Yervoy) Islet Cell Transplantation Isolated Small Bowel Transplant Ketogenic Diet as a Treatment of Refractory Epilepsy Laboratory Testing for HIV Tropism Laparoscopic, Percutaneous and Transcervical Techniques for the Myolysis of Uterine Fibroids Local or Whole Body Hyperthermia Lumbar Spinal Fusion Lung Volume Reduction Surgery for Severe Emphysema Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD) Measurement of Lipoprotein-Associated Phospholipase A2 (Lp-PLA2) in the Assessment of Cardiovascular Risk Microprocessor-Controlled Prosthetic for the Lower Limb MRI of the Breast Multianalyte Assays with Algorithmic Analyses for Predicting Risk of Type 2 Diabetes Myocardial Sympathetic Innervation Imaging in Patients with Heart Failure Myoelectric Prosthesis Components for the Upper Limb 059 Natalizumab (Tysabri ) 014 Neuromuscular Electrical Stimulation (NMES) Noninvasive Prenatal Screening for Fetal Aneuploidies Using Cell-Free Fetal DNA Nutrient/Nutritional Panel Testing Occlusion of Uterine Arteries Using Transcatheter Embolization Ocriplasmin for Symptomatic Vitreomacular Adhesion Ocular Photoscreening in the Primary Care Physician's Office as a Screening Tool to Detect Amblyogenic Factors 058 Omalizumab (Xolair ) 041 Orthognathic Surgery Oxygen Therapy PathFinderTG Molecular Testing Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT) 4

5 Peripheral Subcutaneous Field Stimulation Pertuzumab for Treatment of Malignancies Photocoagulation of Macular Drusen Polysomnography for Non Respiratory Sleep Disorders Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis 151 Quantose Impaired Glucose Tolerance (IGT) Test Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors Radiofrequency Ablation of Primary or Metastatic Liver Tumors Radioimmunoscintigraphy Imaging (Monoclonal Antibody Imaging) Using Technetium- 99m Nofetumomab Merpentan (Verluma) Radioimmunotherapy in the Treatment of Non-Hodgkin Lymphoma Real-Time Intra-Fraction Motion Management During Radiation Therapy Recombinant and Autologous Platelet-Derived Growth Factors for Wound Healing and Other Non Orthopedic Conditions Reduction Mammaplasty for Breast-Related Symptoms Scintimammography and Gamma Imaging of the Breast and Axilla Sensory Stimulation for Coma Patients Serum Biomarker Human Epididymis Protein 4 (HE4) Serum Holo-Transcobalamin as a Marker of Vitamin B12 (i.e., Cobalamin) Status Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy Sublingual Immunotherapy as a Technique of Allergen-Specific Therapy 045 Suit Therapy 564 Surgical Guidelines (Secondary, Multiple Procedures, Co-Surgeons, Assistant Surgeons, Stand- By Physicians, Microsurgery/Microdissection) Surgical Treatment of Bilateral Gynecomastia Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome Sympathetic Therapy for the Treatment of Pain Temporomandibular Joint Dysfunction Thermal Capsulorrhaphy as a Treatment of Joint Instability 135 Thyroid Disease Testing Transanal Endoscopic Microsurgery (TEMS) Transcatheter Arterial Chemoembolization to Treat Primary or Metastatic Liver Malignancies Transcoronary Ablation of Septal Hypertrophy (TASH) Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence Tumor-Treatment Fields Therapy for Glioblastoma T-Wave Alternans Ultrasonographic Evaluation of Skin Lesions Ultrasonographic Measurement of Carotid Intimal-Medial Thickness as an Assessment of Subclinical Atherosclerosis Use of Common Genetic Variants (single nucleotide polymorphisms) to Predict Risk of Nonfamilial Breast Cancer Uses of Monoclonal Antibodies for the Treatment of Non-Hodgkin Lymphoma and Acute Myeloid Leukemia in the Nonhematopoietic Stem Cell Transplant Setting 5

6 Vagal Nerve Blocking Therapy for Treatment of Obesity Videofluoroscopic Evaluation of Velopharyngeal Dysfunction Wireless Pressure Sensors in Endovascular Aneurysm Repair 153 Zika Virus Risk Assessment 6